casemark/pi-intake-form

Personal Injury Client Intake Form

Drafts a fillable intake form for prospective personal injury clients that supports conflict checking, statute-of-limitations tracking, case evaluation, and engagement setup.

Prerequisites

1. Jurisdiction — state of incident and client residence (determines SOL, comparative fault rules, damage caps, no-fault requirements).
2. Firm details — firm name, address, contact info, fee structure (contingency percentage, cost advancement policy).
3. Documents already provided — accident reports, medical records, photos, correspondence — to pre-populate fields and generate follow-up questions.

Output Structure

Generate a fillable intake form with the following sections in order. Calculate and flag the statute-of-limitations deadline prominently at the top based on jurisdiction and incident type.

1) Client Identification

| Field | Notes | |---|---| | Full legal name | As on government ID | | Former names / aliases | For conflict checking | | Date of birth | | | SSN (last 4 only) | Include privacy notice | | Residential address | | | Mailing address (if different) | | | Marital status / spouse name | Loss-of-consortium relevance | | Dependents (names, ages) | Wrongful death relevance |

2) Contact & Communication

| Field | Notes | |---|---| | Primary phone | Mobile / landline | | Secondary phone | | | Email (personal / work) | | | Preferred contact method | Phone / email / text / portal | | Do NOT contact at | Confidentiality concerns | | Text/email consent | Security limitation warning | | Authorized recipients | Others permitted case info | | Interpreter / accommodation | Language or accessibility needs |

3) Incident Details

• Date of incident — flag SOL deadline (verify jurisdiction-specific period)
• Location — street address, city, county, state
• Type — motor vehicle, slip/fall, premises liability, product liability, medical malpractice, dog bite, workplace, other
• Narrative — client's own words, chronological
• Conditions — weather, road, environmental (if applicable)
• Police / incident report — report number, agency
• Witnesses — name, phone, relationship, observations
• Photos / video — scene, injuries, property damage

4) Parties Involved

For each opposing party and additional involved parties:

| Field | Details | |---|---| | Full name | | | Role | At-fault driver, property owner, employer, manufacturer, etc. | | Contact info / address | | | Insurance carrier & policy # | If known | | Attorney (if represented) | Name, firm, contact | | Employer | If commercial vehicle / on-the-job | | Relationship to client | Stranger, employer, landlord, etc. |

Ensure every named person/entity is captured for conflict-system intake.

5) Injuries & Medical Treatment

• Injuries sustained — body parts, diagnosis if known
• Ambulance transport — destination facility
• ER / urgent care — date, facility
• Treating physicians — name, specialty, facility, treatment dates
• Ongoing treatment — PT, scheduled surgery, pain management
• Pre-existing conditions — same body parts or related (critical for causation)
• Lost work days — dates, employer, wage rate
• Current symptom status — improving / stable / worsening
• Medical records authorization — HIPAA-compliant release attached

6) Insurance Information

| Type | Carrier | Policy # | Limits (if known) | |---|---|---|---| | Client auto | | | | | Client health | | | | | UM/UIM coverage | | | | | MedPay / PIP | | | | | At-fault liability | | | | | Homeowner's / renter's | | | | | Umbrella | | | |

• Recorded statement given? — to whom, when (flag as red flag)
• Signed anything from opposing insurer? — flag immediately

Note: no-fault states require adjusted insurance sections [VERIFY jurisdiction].

7) Property Damage

• Vehicle year/make/model, current location
• Repair estimate or total loss determination
• Rental car status
• Personal property damaged

8) Prior Legal History

• Prior attorneys on this matter — name, firm, dates, reason ended
• Pending / prior litigation (past 10 years) — case, court, status
• Prior PI claims — critical for credibility and IME preparation
• Criminal history — may be discoverable
• Bankruptcy filings — affects claim ownership
• Family members with matters at firm — conflict check

9) Financial / Fee Discussion

• Employment status and occupation
• Income range (bracketed: <$25K / $25-50K / $50-100K / $100K+)
• Contingency fee explanation — plain-language description
• Cost advancement acknowledgment
• Lien awareness — Medicare, Medicaid, ERISA, workers' comp, child support

State that a separate written contingency fee agreement will follow if the firm accepts the matter. Do not include a fee agreement in the intake form.

10) Authorizations & Disclosures

Include with signature lines:

• [ ] No attorney-client relationship disclaimer — intake does not create representation
• [ ] Medical records authorization (HIPAA-compliant, separate signature)
• [ ] Employment records authorization
• [ ] Insurance records authorization
• [ ] Third-party communication consent
• [ ] Data privacy notice
• [ ] Text/email communication consent (with security warnings)
• [ ] Accuracy acknowledgment

Signature blocks: prospective client, intake attorney, date.

Guidelines

• Flag SOL deadline at top of completed form; verify jurisdiction-specific periods.
• Use plain language throughout — clients are often injured and stressed.
• Pre-populate from uploaded documents; generate specific follow-up questions for gaps.
• Capture all named persons/entities in conflict-check-compatible format.
• Note state-specific variations: no-fault insurance, pure vs. modified comparative fault, damage caps [VERIFY].
• Flag red flags early: prior recorded statements, signed releases, pre-existing conditions in same body part, approaching SOL.
• Formatting: minimum 11pt body, adequate white space, section headers, fillable fields.
• Use [VERIFY] for all jurisdiction-specific rules before finalizing.

Cross-references

• @demand-letter-personal-injury
• @medical-records-summary
• @contingency-fee-agreement
• @hipaa-authorization